Managed Care - April 2008 - (Page 9) LEGISLATION & REGULATION want, knowing that it won’t affect how much insurers pay them or in many cases how much they earn. “In today’s managed care world, what a doctor charges is almost moot,” says Rucci. “You can charge a million dollars for X, but if your insurer rate is $70, that’s what you’ll get paid.” For Consumers Union Programs Director Chuck Bell, though, the UCR controversy has all the appearance of simple fraud. Consumers are being stuck with higher bills than what they were promised when they decided to join a PPO, says Bell, and that generated complaints to the AG’s office. Bell joined hands with AMA president-elect Nancy Nielsen, MD, and others when Cuomo leveled his blast against Ingenix and UnitedHealth Group. The AG spelled out the method that Ingenix used to “rig” the data in his letter of intent to sue. Ingenix collects data on a broad range of charges in order to calculate the UCR. To skew the numbers lower so it can deflate the UCR rates, Cuomo alleges, Ingenix routinely eliminated a large number of steep charges — outliers? — before it crunched the numbers. In particular, more expensive procedures were excluded. Nothing was done to factor in who delivered the service — whether, for example, an intern or a hospital’s chief of surgery had done a procedure. On top of that, Cuomo claims, companies sending charge data to Ingenix excluded high costs as well. And Ingenix never audited the data to determine accuracy. This fight is likely to go on much longer than the swift deal Cuomo achieved on physicians’ ratings, Bell predicts. “There may be large amounts of compensation involved. The remedy could involve the spin-off of Ingenix to become an independent company. That’s a major step.” But insurance groups are digging in for a fight as well. From their perspective, $200 for a 15-minute visit works out to $800 an hour. Isn’t that exactly what health plans are supposed to resist? “The consumers are paying that because that is precisely what out-of-network is,” says Helen Darling, president of the National Business Group on Health. The out-of-network benefit “is not intended to underwrite an inefficient system. There’s some subsidy to people who go out of network. I think they get a good, reasonable rate, and in an HMO they get zero. If you choose a PPO you get something; in an HMO you get nothing.” America’s Health Insurance Plans, the industry trade group, says Cuomo’s move is badly misguided. “It’s disturbing that the office of the attorney general would focus on increasing payments to the small number of physicians who do not participate in health plan networks and charge rates that are more than double what Medicare pays,” says AHIP President and CEO Karen Ignagni. “It doesn’t sound even remotely fair,” Darling adds. “The monitoring of increases in physician payment goes back many, many years — more than 30. Insurance companies have had to track how doctors’ fees increase. You could do something like Medicare and say you were going to pay them X. Instead, insurance companies have tracked increases and they periodically update the fee schedule. And one reason they do that — which is positive from the physicians’ point of view — is to make sure fees track but don’t lead those increases. Physicians have every reason to keep charging more and more. To what extent should third-party payers, or anyone paying, track and periodically update the fee schedule so that it’s not following galloping inflation?” Darling isn’t speculating about Cuomo’s motive for tilting against the MCO windmill again, but heath plans have long been a convenient target for any politician looking for a high profile. “It doesn’t sound even remotely fair,” says Helen Darling, president of the National Business Group on Health, of New York’s effort. Easy target? “Everybody cares about health care,” she says. “There are things we don’t pay for because they’re ineffective, but some people will always say, ‘I don’t care if it’s not effective, I want it.’And somebody will make a headline out of it. There’s a lot of publicity and appeal in taking on anything that’s unpopular.” “If he goes after this, it will have a national impact,” says Rucci. “The data are used all over the country.” MC APRIL 2008 / MANAGED CARE 9
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